¶ Differentiating Social Anxiety Disorder in DSM-5
Hello and welcome to our demystifying disorder series here at Licensure Exams . I'm Dr Linton Hutchinson , joined by my co-host , Stacey Frost . In today's episode we'll be talking about how you can differentiate social anxiety disorder from general anxiety disorder and autism spread from disorder in the DSM-5 TR .
Hi there everyone , and a shout out to Linda , a therapist in Berlin , germany , who suggested the topic of today's episode Wielen Dunklinde ist Freude misch , das Freude hierbei uns sind , which for you non-German speakers out there , and maybe I butchered it a little bit , but that means thanks so much . I'm glad that you're here with us today .
So let's start by reviewing the diagnostic criteria for social anxiety disorder .
OK .
The hallmark of this disorder is a persistent fear or anxiety about social situations where the client is exposed to possible scrutiny or negative evaluation by others . A few examples include performant situations like giving a speech , like a podcast , or informal social gatherings , including conversations with others , or talking to strangers for talking about a child .
Their anxiety has to occur in the presence of peers , not just for the adults . The client is worried that they will appear anxious they might be stumbling over their words sweating , blushing , trembling , that kind of thing and that they'll be negatively judged by others , for example , being perceived as boring or weird , crazy , stupid .
The client might even worry that their anxious behavior will offend other people , and this sort of worry tends to be common in clients who have a cultural background with strong collectivist views Right Sort of like to Cahill . OK , I'll bite Linton who's to Keio ?
Well , I'm glad you asked To . Keio is a 25 year old Japanese American guy who has intense anxiety about going to meet his Japanese girlfriend's family . Imagine that he worries that if he appears awkward or stumbles over his words due to anxiety , it will be seen as impolite and offensive to her traditional Japanese parents .
Who would have known , who would have thought that ? But he is afraid that they may think he is not respecting them properly and collective cultures . There's a strong norm about not embarrassing the family or group , so social anxiety may manifest as a fear of unintentionally breaking social norms and offending others because of one's anxious symptoms .
The person recognizes that fear is excessive , but they cannot control it .
Well , that is a perfect example to illustrate how social anxiety can present differently depending on the cultural context .
Right .
The underlying fear of negative evaluation is still there , but the specific worries that the client has are tied to social norms and they vary cross-culturally . Ok , so back to the last few bits of criteria for social anxiety disorder . In children you might see crying tantrums , although , come to think of it , you might see this behavior in adults too .
Right , especially if you're at Walmart .
Yes , I have seen a fair bit of adult tantruming there . That's a good point , and clinging to parents as manifestations of the anxiety that the child feels . And the other criteria here is that the social situations almost always induce a fear or anxiety response .
Ok , Stacy , but that also includes situations like going to the dentist , for example .
Oh , good one , okay yeah .
Well , just up into a few years ago I really sort of dreaded going to the dentist , but you can only avoid that so long . So you know what Beck did to help me out .
Oh , yes , I remember this well . So , as I recall , beck would say that you'd be going off to the beach for the day where we are right now . Yep , yep .
And then she'd let you get all ready and you swim the suit you know , get your towel together , your suntan lotion and then , instead of making that you know left hand turn Right , you go right and drive directly to the dentist office .
Well , I always did get a big laugh and I thought of that , and I'm sure Dr Lane and his staff at distinctive dentistry did too .
Okay , okay . She only had to do that for a few decades . I finally got over my anxiety .
A little bit of exposure therapy . Okay , well , a bit of a slow learner though , aren't we , linton ? Alright , but back to your question . Your fear of going to the dentist office would be classified as a specific phobia , not social anxiety disorder . But , linton , I also wonder if you developed a fear of going to the beach as a result of Beck's intervention .
No , I didn't like . For example , we're here right now .
Okay , all right . Well , I'll take your word on that one . Linton , you do have , you know , one of your backgrounds up , so I can't really tell where you are . So , just like depressive symptoms , anxiety can manifest in different ways depending on the client's age . You'll also see avoidant behavior . The client avoids social situations where they feel exposed .
Or if they have to be in those situations , they endure them with an intense fear or anxiety . And finally , the client's fear or anxiety is way out of proportion to the actual threat posed by the situation .
Wait , wait , there's one more Duration . Oh okay , yes , that's right Very very important .
Yes , yeah , very important part of the criteria . So the anxiety about social situations and avoidant behavior typically lasts for at least six months or more .
Okay , remember that six months or longer is important . You may have to have that as a Criteria , this on an exam . So what about really shy people , though not to name any names ? There is safety , yes .
Well , shyness is a pretty common personality trait , linton , although I'm pretty sure that you have never been shy a day in your life . Dr Extraverge , you could initiate a friendly conversation . It's just about anyone , even the most reserved or standoffish person .
I'm sure , because I've been with you at the public's checkout when you ask people what their favorite animals yes , and I've gotten some pretty interesting responses from that question .
Ziggy , who works in the meat department , was Thanks , and John actually has a pet octopus . Guess where he works . Oh , let's see oh no , he doesn't work at the seafood counter .
Very interesting , I wonder the person who works a dairy with their favorite animals . All right , so back to your original question . Okay , no shyness by itself is not pathological .
Right , okay , I'll just have to take your word .
Well , like all disorders in the DSM 5 TR , when the symptoms , in this case fear or anxiety cause problems with Relational , occupational , social or educational functioning , that's when you should start considering a disorder , in this case a diagnosis of social anxiety .
Okay , so to sum it all up , social anxiety disorder involves an intense fear of social situations that leads to avoidance or distress that interferes with normal functioning , and that fear , anxiety or avoidance persists for six months or more .
Okay , remember that . Six months or more . That's right now . I've got a question for you , stacey , you're getting a little anxious there .
Oh , whenever you ask questions , all right , go on , tell me what's your question .
Okay , what if your client only gets really anxious about performing in public ? Maybe they have to give a presentation , let's say like a podcast , for example , or perhaps their musician dancer or an athlete , but aside from that , they don't have any other issues with social situations . Do they have social anxiety disorder ? Who is that singer ?
Was it Barbara Streisand ?
I don't know . I think she did Social anxiety disorder . I imagine it's actually more common than we think . I mean , you know it's a it takes a special skill set , I think , to go up in front of thousands of people , especially singing Okay , so you're going to love this Linton . So in this case , you're going to be looking at a specifier .
Oh no , why are I surprised ? Your favorite , Specifiers .
Well , it wasn't terribly long ago that I would have said a big no to recording podcasts and webinars , but after working with you these past 10 plus years , I think I'm going on like 13 years now , linton . Yeah , and giving talks at conferences , posting webinars and doing these lovely podcasts together . I think I'm pretty well past my own performance anxiety .
But you know , when I think about this , I look back and I say this was your plan all along , wasn't it ?
Right , Well , you've got me there . Stacey , you know we are planning to go to the Florida Mental Health Counseling Association annual meeting next year . That you missed this year .
Oh , I guess that must have slipped my mind .
Maybe , I should have told you that we were going to go to the beach instead .
Well , the beach actually sounds really nice . Right about now it's about like 35 degrees outside where I am .
Oh really , it's 69 right now . That's your .
Hawaiian shirt on .
I love it , I do .
All right . So how about a case to illustrate social anxiety disorder for our test takers , Linton ?
Okay , let's talk about Daniel , and Daniel describes experience intense anxiety when having to interact with others , especially people that he doesn't know too well . He's particularly anxious about giving a presentation at work , going on any job interviews or speaking up in meetings . Daniel worries that he will say something embarrassing or people just think he's ridiculous .
He mentions that he experienced a panic attack on more than one occasion . His anxiety builds as soon as he knows that one of these social situations is coming up . He loses sleep the night before to excessive worrying . When in the anxiety producing situation his heart races , he starts sweating profusely and his mind just goes totally blank .
Afterward he is plagued by thoughts about how poorly the interaction went . Due to that anxiety . He's turned down a couple job promotions at work that require more public speaking and leadership kind of a role . He avoids attending any social functions , refuses to date anybody and has trouble forming close relationships .
He reports feeling , of course you can imagine lonely and to set aside with his life .
Okay , I think I've got the key points there , so I've got a question for you now , linton .
Oh , no what .
Feeling a little nervous , a little anxious . Okay , so why is social anxiety disorder a better fit for Daniel than , say , generalized anxiety disorder ?
Okay , well , you know this is the kind of session that you might find on an examination that you have to do . Okay , so you have to think . There's a few key reasons why Daniel's symptoms fit better with social anxiety disorder rather than generalized anxiety disorders . And what are they ?
The main trigger for Daniel's anxiety and avoidance is social situations , especially those involving potential negative evaluation or judgments from anybody else . His fear is focused on social context .
Specifically , he does not endorse excessive worry about routine life circumstances like health , finances or household responsibilities , safety of loved ones and hypothetical future events .
If Daniel mentioned those kind of concerns in a session , that would be more indicative of what Of generalized anxiety disorder and and Daniel's anxiety spikes in anticipation of specific feared social situations , whereas generalized anxiety is more persistent and unprovoked . It just is there .
Okay , alright , here's another one . So what about autism spectrum disorder ? Both ASD and social anxiety disorder involve challenges and difficulties with social interactions .
I see . Well , Stacey , why don't you tell me about that ?
Alright , turn the tables back on me , alright . Well , this is important information for you guys to know , because there are gonna be choices , you know , like this , on a licensure exam right , so you have to distinguish between disorders , Alright .
The critical difference , Linton , is that in social anxiety disorder , the social difficulties stem from a fear of negative judgment .
In contrast , the social challenges associated with autism spectrum disorder are due to core deficits in social communication interactions and inflexible , restricted behaviors , such as deficits in social emotional reciprocity , abnormalities in eye contact and body length , and overall difficulties in developing , maintaining and understanding relationships .
Oh , that was a mouthful , Linton .
Oh man .
Yeah , so something else that provides a clue to autism spectrum disorder is the age of onset .
Yeah , that would .
Yeah , yeah , so if the client symptoms appear later in adolescence , then that's more supporting evidence of an anxiety disorder . The typical age of onset for autism spectrum disorder is during early childhood and that disorder autism is classified as a neurodevelopmental disorder .
So the age of onset for those disorders tends to be in the early childhood developmental stage .
So that would be a good differentiating criteria for these two , wouldn't ?
it ? Yeah , absolutely . If you knew the age when this kind of stuff started for the client , then you could . It would help more support one disorder versus the other .
Okay , so how about giving us a brief summary of what we've discussed in this episode ? Okay ?
Alright , sure thing . So put simply , clients with social anxiety disorder feel afraid or anxious in social situations where other people might judge them or think badly , and this makes the person want to avoid being around people or they feel really uncomfortable when they have to be around people in social situations .
Now there's a specifier performance only that can be used with social anxiety disorder , when the anxiety is limited to public speaking or performing publicly .
¶ Recognizing Anxiety and Autism Disorders
Right .
Alright , and so a few differentials that we talked about were generalized anxiety disorder , which involves excessive worrying about a variety of topics like health , finances , family safety , and that the anxiety is much more constant and it's unprovoked , unlike social anxiety disorder , where anxiety spikes around specific social interactions .
And then there's autism spectrum disorder , which involves core deficits in social communication interaction and restrictive , repetitive behaviors . The social difficulties stem from these core deficits rather than a fear of negative evaluation , as we would see with social anxiety disorder . And finally , yeah , the age of onset also provides us with a big clue here .
Social anxiety disorder typically appears for the first time in adolescence , while autism spectrum disorder symptoms emerge in early childhood .
Well , that was a great summary . Thanks , Stacey and all of you . Please join us next time as we continue to review topics together so you can pass your exam with flying colors . Until next time , remember , it's in there , it's in there .
Alfie to Zan Linda .